ANNEX E: COVID-19 MONITORING TOOLS

Tool Description
Para sa mga Magulang For distribution to parents of learners who will report to school; may be part of the parent's consent that they
will sign in approving learner's physical reporting to school

Notice to Reporting Personnel For display at the entrance gate and/or for distribution to reporting personnel (may be signed at least once)

Visitor's Declaration Form For visitors who will enter the school; to be accomplished by the visitor and assessed properly by designated
school staff prior to approval of entry (there must be guidelines as to when visitors may be accommodated and
for what identified purposes)

Teacher's Record For teachers to keep per class, each day, during health routine inspection (teacher may be provided with step-by-
step instruction on how to facilitate the inspection using the tool)

Logsheet For safekeeping at the Clinic c/o the Clinic Teacher/Nurse to record all cases managed at the Clinic

School Head's Summary The school head shall keep a summary of the health status of learners and personnel, especially those who will
manifest COVID-19 symptoms for proper monitoring and identification of necessary next steps
 Symptoms Translation/Description
01 Fever Lagnat/ang body temperature ay 37.5 C o higit pa
02 Cough Ubo
03 General weakness Panghihina ng katawan
04 Fatigue/Tiredness Pagkapagod
05 Headache Pananakit ng ulo
06 Muscle/joint/body pains Pananakit ng katawan, kalamnan, kasu-kasuan
07 Sore throat Pananakit o pamamaga ng lalamunan
08 Colds/runny nose Sipon
09 Difficulty of breathing Pagkahapo o hirap sa paghinga
10 Loss of appetite Kawalan ng ganang kumain
11 Nausea Nasusuka
12 Vomiting Pagsusuka
13 Diarrhea Pagtatae
14 Loss of smell Pagkawala ng pang-amoy
15 Loss of taste Pagkawala ng panlasa
Rashes
16 Mga butlig sa balat; pamumula ng balat (maaaring makati o hindi)
Others
17 Mga sintomas o obserbasyon sa pangangatawan o pagkilos ng tao/bata na kailangan ng atensyong medikal
 Paalala sa mga Magulang/Guardian

Kung ang inyong anak po o ang sinuman sa inyong sambahayan ay kasalukuyang nakararanas o
nakaranas sa nakalipas na 14 na araw ng alinman sa mga sumusunod na sintomas, mangyari pong
huwag na munang papasukin ang bata sa eskwela.

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Huwag din po munang papasukin sa eskwelahan ang inyong anak kung siya o ang sinuman sa inyong
sambahayan ay nagpositibo sa COVID-19, naging close contact ng COVID-19 case, o nadiagnose sa
pneumonia.

Ipagbigay alam po agad ang sitwasyon sa kanilang guro na si G/Gng/Bb. _______________, sa

numero bilang ___________________, upang maisaayos ang alternative delivery mode para sa
kanilang pag-aaral habang sila ay nasa bahay.

Mangyari pong imonitor ang kondisyon ng inyong anak o kasama sa bahay, at iulat sa inyong
Barangay Health Emergency Response Team (BHERT), Barangay Health Station, o Rural Health Unit,
kung kinakailangan, upang sila ay mabigyan ng kaukulang lunas.

Ipinapabatid din po ng pamunuan ng ___________________________________ na imomonitor po

ng kanilang mga guro ang mga mag-aaral na pumapasok sa paaralan at ipagbibigay-alam agad sa
inyo at sa mga kinauukulan kung sila ay ma-obserbahan o maiulat na nakakaranas ng alinman sa
mga sintomas na nabanggit sa itaas.

Mangyari pong itago o idisplay sa inyong bahay ang paalalang ito upang magsilbing gabay para sa
 Notice to Reporting Personnel

By proceeding to report to school today, you guarantee the school management that neither you nor
any member of your household experiences any of the following symptoms:

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You also confirm that neither you nor any member of your houshold is currently tagged as COVID-19
positive or a close contact of a COVID-19 positive case, or has been diagnosed with pneumonia.

If you experience any of the abovelisted symptoms while you are in school, kindly report immediately
to the School Clinic for appropriate assessment and/or referral as needed.
 Health Declaration Form

Source: COMELEC (Note: Ask DOH of standard declaration form, and appropriate action per
reported information [e.g., do not allow entry if they checked "yes" to any statement?], if
available.)
 CLASSROOM DAILY HEALTH MONITORING TOOL FOR COVID-19

Grade Level: Section:

Instruction: Write under each column date the code(s) of the symptom(s) observed in the learner during the routine inspection, during the conduct of the class, or as
reported by the learner or their classmates. Refer to the list of symptoms below and their respective codes:

Fv Fever F/T Fatigue/Tiredness ST Sore throat LoA Loss of appetite D Diarrhea R Rashes

C Cough HA Headache C/RN Colds/runny nose N Nausea LoS Loss of smell Others

Symptoms Observed/Reported
NAME 2021-09-13 2021-09-14 2021-09-15 2021-09-16 2021-09-17
Monday Tuesday Wednesday Thursday Friday

Note: As soon as any of the listed symptoms is observed among any of the learners, the teacher is expected to send the learner to the School Clinic immediately for the proper
management by the School Clinic Teacher or health personnel.

Submitted by: Noted by:

Classroom Adviser Clinic Teacher

 Procedure for Reporting, Management, and Referral
Person Activities Means of Verification Resources Needed
Note: In case of life-threatening emergency, bring the learner to the nearest health facility as soon as possible, while informing the parent of the situation. Necessary first aid
must be provided until the learner is attended by the medical personnel in the facility.
Classroom teacher Performs initial/basic Daily Health Monitoring Tool for Thermometer, printed health
Step 1 asssessment of the condition of COVID-19 monitoring tool (1 sheet per week per
the learner (either through class)
Classroom teacher routine
Sends inspection
text message orto as
theobserved
Clinic Mobile phone with load
(Option 1)
Teacher informing them about
Step 2a
the symptomatic learner
(Option 1) Clinic assistant Fetches the symptomatic learner Clinic assistant
Step 2b from the classroom to the clinic
(Option 2) Classroom assistant Accompanies the symptomatic Classroom assistant
Step 2 learner to the clinic
Step 3a Clinic teacher/nurse Logs the information of the Logsheet (Name, reported
Clinic teacher/nurse learner condition of the learner symptoms)
Assesses
Step 3b
(Verify the symptoms)
Clinic teacher/nurse Provides first aid treatment and Referral Slip Referral Slip
initiates necessary preparations
Emergency Step 4
for sending the learner to the
nearest health facility (e.g.,
Clinic teacher/nurse prepare referral
Contacts slip,Medical
the DepEd facilitate Mobile phone with load; contact
Officer or the MHO/RHU doctor information of the Medical Officer
Step 4a
(in case there is no DepEd assigned for the school and of the
Medical Officer) MHO/RHU doctor; ensure
DepEd Medical Provides instruction to the clinic Logsheet (Doctor's order); arrangement
Mobile phonewith
withthe MHO/RHU
load (access to
Officer/MHO/RHU doctor teacher (which may include Photo/Soft copy of messenger/viber);
Step 4b reporting to the BHERT or Prescription/Instruction Slip (Sent Prescription/Instruction Slip
sending to the nearest hospital through Messenger/Viber)
facility as needed, based on the
assessment of the Medical
 Clinic teacher/nurse Contacts the parent about the
condition of the learner if
instructed by the Medical Officer, medication to be given)
notifies the parent about the
Medical Officer's instruction,
Step 4b.i (As needed) including prescribed treatment
or medication, and asks the
parent to fetch the child from
school, if needed
Clinic teacher/nurse Makes necessary preparations
and coordination to send the
learner to the nearest health
Step 4b.ii (As needed) facility, if instructed by the
Medical Officer
Clinic teacher/nurse Contacts the BHERT, if instructed Logsheet (Remarks; Reported case); Mobile phone with load; contact
by the Medical Officer
Step 4b.iii (As needed)
Clinic teacher/nurse Provides first aid treatment as
instructed by the Medical Officer
Step 5
Path 1
Logsheet (Remarks; that parent was
notified and informed about the
Logsheet (Referred to); Referral Slip Mobile phone with load; contact
copy of communications to the
BHERT (at least text message)
Logsheet (Doctor's order)
~Mobile phone with load; contact
information of the parent
~Consent to participate in the F2F
classes must cover consent to allow
management of symptoms while in
school (including sending to health
facility in case of emergency, reporting
to BHERT, as needed), as well as crucial
information about the learner's health
(e.g., allergies, medications, etc.) Note:
This particular section will be
information of the nearest health
facilities; Referral Slip
information of the BHERT that has
jurisdiction to the residence of the
learner (Clinic needs list of contact
information of all BHERTs of the
learners reporting to the school);
Action Slip (report to BHERT)
Medicines to address symptoms; first
aid kit; other equipment (non-contact
thermometer, pulse oximeter,
nebulizer, forceps, BP apparatus,
oxygen tank, sterilizer); (Refer to list of
equipment that must be present in the
clinic before the school is allowed to
 (Option 1) Clinic assistant Accompanies the learner back to
Step 6 the classroom once cleared
(Option 2) Classroom assistant Fetches the learner from the
Step 6 clinic to the classroom once
Path 2a (If parent is asked to fetch the child; from 4bi) cleared
Step 6 Parent Arrives in the school to fetch the
Clinic teacher/nurse learner instruction/important Logbook (Remarks); "May Go
Provides MGH Slip, including list of
information to the parent Home"/MGH Slip (with copy signed reminders/instructions for the parent
Step 7 by the parent, to be left to the (including what to monitor; need to
Guard and then returned to the report to BHERT as needed; need to
Clinic) inform school if the learner tests
Clinic teacher/nurse Follows-up on the condition of Logsheet (Follow-up status) positive; whenwith
Mobile phone to seek clearance
load; contactprior
Step 8
the learner, including results of information of the parent
The School Head, together with the clinic teacher, is expected toCOVID-19
prepare atest (if applicable)
summary of reported/managed/referred learners, and their condition.
Path 2b (For COVID cases; if learner is referred to BHERT; from 4biii)
Classroom teacher/clinic Receives information from Parent's consent form must include a
Step 9a teacher/nurse BHERT/parent that the learner(s) provision that parents are required to
is/are positive for COVID-19 report to the school the COVID-19 test
Classroom teacher/clinic Informs the school head about results of their children
Step 9b teacher/nurse the case(s)

School head Convenes concerned personnel

Step 10a to inititate contact tracing
among the classmates and
School head teacher(s)the
Prepares of the positive
list of case(s)
all close
Step 10b
contacts of the positive case(s)
School head Informs the families of the close
Step 11a
contacts about the situation
School head Informs and submits to their Incident report
Step 11b respective BHERTs incident
reports, providing information
School head about the situation,
Follows-up and the list
on the condition of
Step 12
the close contacts, including
Reminders: results of COVID-19 tests (if

1. Medical certificate/clearance may be required before learners are allowed to return to face-to-face classes, subject to the approval of the DepEd Medical Officer.

2. There must be avaible alternate clinic teachers/nurses to take over the management of the clinic in case the first batch of clinic teachers/nurses become close contacts of a
positive case or test positive for COVID-19.
Date Time Name Age Sex Grade & Teacher Adviser Chief Complaint(s) Doctor's Order Treatment Administered By Remarks Follow-up Status
Admitted Section [Reason(s) for the clinic [To be initialed by the Medical Officer [Indicate how the instructions of the doctor were [As needed; Date/Status]
visit/reported symptom(s)] upon visit]/ Supported by the followed, as well as other actions taken; e.g., ordered to
doctor's Prescription/Instruction return to classroom, what time; reported to BHERT,
Slip specify contact number; informed the parent about
instructions, fetched by; etc.]
_ Administer treatment Paracetamol 5ml, given at
_ Contact the parents 10:30 am
_ Refer to health facility
_ Report to BHERT
 SUMMARY OF HEALTH STATUS OF PERSONNEL AND LEARNERS
For the Month of: ________________
School

Name Category Grade Level/Section Date Reported Symptom(s) Action Taken COVID-19 Status per
(Personnel/Learner) Observed/Reported (Referred to) Follow-Up
(Positive/Negative)
MAY GO HOME SLIP

Date:
Name
Age
Sex
Grade/Section
Teacher-Adviser

This certifies that the learner has been provided initial management at the clinic, with instructions from:
Name of Doctor:

The doctor has given instruction that the learner may go home/be fetched by his/her parent/guardian.

Signed:

Clinic Teacher/Nurse

This certifies that I have been provided important information/instructions by the clinic teacher/nurse:

Signed:

Name of fetcher:
Relation to the child:
Time fetched:

Present this May Go Home Slip and cut and leave the upper portion of the slip to the guard before leaving the school.

This lower portion may be brought home by the parent/fetcher.

REMINDERS TO THE PARENT

_ Please monitor the following:

_ Please consult with…

_ Your child has been reported to the BHERT ( __________________ ); please coordinate with them for the next steps
_ Please inform the school immediately if your child tests positive for COVID-19.
_ Medical certificate/clearance is required before the learner is allowed to return to face-to-face classes, subject to
the approval of the DepEd Medical Officer.

Other instructions:
<Address>

<Name of Doctor>
<Position>
List of symptoms (per DOH DM 2020-0512)
PMA